Post-dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal-epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = -0.48 [95% confidence interval (CI): -0.88 to -0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = -0.44 (95% CI: -0.67 to -0.21)], epidural morphine [one trial, quality score = 4, risk difference = -0.36 (95% CI -0.59 to -0.13)], and cosyntropin [one trial, quality score = 5, risk difference = -0.36 (95% CI -0.55 to -0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed.

Objectives: Central adiposity and large neck circumference are associated with obstructive sleep apnea (OSA) in adults but have not been evaluated in children as predictors of OSA. Study objectives were to determine whether (1) anthropometric measures including neck-to-waist ratio are associated with OSA in older children; (2) body fat distribution, measured by neck-to-waist ratio, is predictive of OSA in overweight/obese children. Methods: Cross-sectional study involving children 7-18 years scheduled to undergo polysomnography at a tertiary care children's hospital. OSA was defi ned as total apnea-hypopnea index > 5 events/h and/or obstructive apnea index > 1 event/h. Recursive partitioning was used to select candidate predictors of OSA from: age, sex, height and weight percentile, body mass index (BMI) z-score, neck-to-waist ratio, tonsil size, and Mallampati score. These were then evaluated using log binomial models and receiver operator characteristic analysis. Results: Two hundred twenty-two participants were included; 133 (60%) were overweight/obese, 121 (55%) male,47 (21%) had OSA. Neck-to-waist ratio (relative risk [RR] 1.97 per 0.1 units, 95% CI 1.48 to 2.84) and BMI z-score (RR 1.63 per unit, 95% CI 1.30 to 2.05) were identifi ed as independent predictors of OSA. Considering only overweight/obese children, neckto-waist ratio (RR 2.16 per 0.1 units, 95% CI 1.79 to 2.59) and BMI z-score (RR 2.02 per unit, 95% CI 1.25 to 3.26) also independently predicted OSA. However, in children not overweight/obese, these variables were not predictive of OSA. Conclusions: Neck-to-waist ratio, an index of body fat distribution, predicts OSA in older children and youth, especially in those who were overweight/obese.

The data on pediatric anesthesia acute severe complications are poorly defined with large variation in the specificity of diagnostic reporting even within studies. We suggest that it is vital for future studies in this area to be based on a standardized system of diagnostic reporting (possibly with a hierarchical system of coding) with adequate description of population details to describe heterogeneity of data.